UConn Law

Newcomer immigrant youth – refugees, asylum seekers, and unaccompanied children – face unique behavioral, social, and learning challenges as a result of trauma. Julian Ford recently co-authored A Trauma-Informed Approach to Judicial Decision-Making for Newcomer Immigrant Youth in Juvenile Justice Proceedings, a primer for juvenile court judges and advocates who encounter immigrant youth. We asked Ford how trauma impacts these children and what doctors should remember when treating them.

Newcomer immigrant youth – refugees, asylum seekers, and unaccompanied children – face unique behavioral, social, and learning challenges as a result of trauma. Julian Ford recently co-authored A Trauma-Informed Approach to Judicial Decision-Making for Newcomer Immigrant Youth in Juvenile Justice Proceedings, a primer for juvenile court judges and advocates who encounter immigrant youth. We asked Ford how trauma impacts these children and what doctors should remember when treating them.

They are impacted by violence in their countries of origin and on the journey to the U.S., as well as by race-related and institutional trauma in this country. Many develop a sense of fear, distrust, and even hopelessness that interferes with relationships, school, adjustment to new communities, and their physical health. These problems can persist for many years.

Q

What behaviors do they exhibit as a result?

These youth are often distrustful as a result of trauma, and can be very withdrawn or impulsive in an attempt to protect themselves from further trauma. This is a form of “survival coping,” which results from chronically not feeling safe. Justice involvement can occur when these youths feel that they must take extreme steps to protect themselves, which can lead to breaking rules — such as at school — or confrontations with law enforcement.

Q

How can physicians provide the best care to these patients?

Immigrant youths and their families, especially recent newcomers, have come to the United States in a period of turmoil and controversy that has heightened the stress they face in coming to a new country and new community. Many may feel reluctant to seek health care for fear of facing prejudice or discrimination. Providing a clear message of welcome and acceptance, in addition to showing interest in learning and respect for their culture and traditions, is essential to forging a positive treatment relationship — and can reduce patients’ anxieties and contribute to better health outcomes.

Expect that it will take some time, often several visits, for these youths and their families to feel sufficiently trusting and safe to fully and actively engage in dialogue and the treatment process. Patience and consistency on the part of the health care professional are a crucial counterbalance to the often harsh and even traumatic encounters many have had with putative helpers and institutional officials during their journey and once in the United States.

Explaining the nature and limits of confidentiality can help reduce fears about being subject to immigration sanctions.

Q

Is there a plan in place to help youths who suffer from this type of trauma?

The National Child Traumatic Stress Network has established more than 15 programs nationally for these youths. [The Center for Treatment of Developmental Trauma Disorders and The Center for Trauma Recovery and Juvenile Justice, of which Ford is the director, are members of the network.] This network was established by the federal government in 2001, and its centers provide public education, counseling, advocacy, and behavioral health treatment services for children and families, as well as consultation to community leaders and policymakers.

Q&A With UConn Law Professor John A. Cogan Jr.

In June, the U.S. Supreme Court turned away yet another challenge to the Affordable Care Act (ACA), commonly referred to as Obamacare. The Court, in King v. Burwell, ruled 6-3 that the government could continue to provide premium subsidies nationwide to middle- and low-income Americans who purchase their health insurance directly from insurers on health insurance exchanges.

The subsidies are a crucial component of the ACA, which requires all Americans to have health insurance. Had the Court ruled against the government, the individual health insurance market would have been thrown into chaos, says insurance law expert John A. Cogan Jr., an associate professor at UConn Law. Unsubsidized, healthier consumers would be driven out of markets, and premium costs would spike.

While the Supreme Court’s ruling brought certainty and stability to the individuals who purchase insurance on the health insurance exchanges, there is still uncertainty for another group – physicians. Recent mega-mergers in the health insurance industry may leave doctors with less bargaining power in the future, possibly affecting reimbursement rates, says Cogan, who has written extensively about health law and policy.

Q

What was the immediate effect of the Supreme Court’s ruling in King v. Burwell?

The major effect was to cement the federal government’s implementation of the law. The case dealt with a very specific issue: the subsidies offered to low- and moderate-income people. Unlike the previous ACA case, King v. Burwell wasn’t a constitutional challenge, it was based purely on a question of statutory interpretation: Could the government give out subsidies? The Supreme Court said yes. Since the constitutional and major statutory challenges have failed, we may see opponents attempt to chip away at portions of the ACA they do not like, but I think it’s safe to say we won’t see any more major cases attempting to unravel the whole law.

Q

In the wake of the decision, we saw announcements by insurer Aetna that it intended to buy competitor Humana, and then that Anthem would buy Cigna. That would bring the number of major health insurers in the U.S. from five to three, with UnitedHealth the third. How will these mergers benefit the insurance companies, and how will they affect health care providers?

The post-merger companies will each have a larger share of the market, thereby consolidating their power. Consolidation allows insurers to increase profits through efficiency gains. But these larger insurers will also gain bargaining power with healthcare providers. This is important because providers are paid directly by insurers. If you have doctors and hospitals negotiating with several different insurers, they have the ability to walk away from any one of those insurers, giving providers some leverage. But if there are only two insurers, that leverage is diminished. Major hospital systems and large physician groups will still have some bargaining power because of their size, but individual physicians will see their bargaining power diminish further.

Q

Will the effect of the mergers be in line with the intent of the law?

The ACA’s express intent was to expand coverage, and it worked. There’s nothing in the ACA regarding industry consolidation. Nevertheless, the fallout of the ACA’s expansion of coverage – efforts by insurers to consolidate market share – was foreseeable. Now that the ACA is here to stay, federal and state regulators will have to wrestle with consolidation issues.